EXPLORATIONS IN NEUROSCIENCE INFORMATION The Explorations in Neuroscience camp is designed for high school students who have an interest in learning more about the brain and spinal cord in health and disease. Further, participants will have the opportunity to interact with faculty and students carrying out neuroscience related research. In addition, they will meet with clinicians from various clinical departments such as Neurology and Neurosurgery. Throughout the course, participants will meet with graduate students in the Neuroscience Graduate Program who will lead discussions and talk about their exciting research. On the final day of the camp, we will provide a session that focuses on the Neuroscience Undergraduate Major where we will discuss career pathways in Neuroscience including those leading to graduate school, medical fields including medicine, dentistry, nursing, and allied health, and other career options. Discussion will include suggestions on how to be successful as students go through their undergraduate programs. Dates: June 3, 2019 June 7, 2019 Place: Department of Neuroscience, Meiling Hall Eligibility: Rising 11 th 12 th graders who have an interest in the nervous system and a potential career in the biomedical sciences (e.g., research, medicine, dentistry, etc.). Students must obtain concurrence from a counselor or science teacher at their school that they are in good academic standing at their school (see application). Cost: $750.00 which includes supplies, meals, snacks, t-shirt, and other accessories. Do NOT send any payments with this application. Payment is due upon acceptance into camp and is non-refundable. We do have a limited number of financial need scholarships available upon request. Questions regarding available scholarships can be sent to ExplorationsInNeuroscience@osumc.edu. Travel: Students should provide their own transportation to/from the OSU campus each day. For those students who plan to drive to campus, parking passes are available for a fee through CampusParc (http://www.campusparc.com/osu). Format: Students will learn through a variety of approaches including: Hands-on lab sessions where students will learn the anatomy of the brain and spinal cord. Presentations by clinicians on new techniques in treating nervous system disorders such as spinal cord injury, Parkinson s Disease and others. Presentations on research being carried out by faculty members in the Department of Neuroscience.
Games designed to show how the brain adapts to a changing environment or how we perceive and attend to the world around us. Discussion/Debate about current topics in Neuroscience (e.g., use of marijuana, use of animals in research). Demonstration of neuroscience methodology (behavioral paradigms, physiological recordings, microscopy). Small group rotations through research labs where faculty/students will demonstrate and discuss their research programs. Discussions with graduate students in Neuroscience Graduate Program and advisors from the Undergraduate Major. Application Instructions: Interested students should complete and email the student application to ExplorationsInNeuroscience@osumc.edu. The pdf application form must be received by via email no later than May 16, 2019. Do not send payment. In addition we require the signature of a teacher or counselor that the student is in good academic standing. Finally, the applicant must write a brief paragraph (250 words) stating why they want to come to this camp. Questions? Please contact ExplorationsInNeuroscience@osumc.edu
THE OHIO STATE UNIVERSITY COLLEGE OF MEDICINE DEPARTMENT OF NEUROSCIENCE Instructions to the student: Complete this application form with your parent/guardian. Email a pdf copy of the completed application to ExplorationsInNeuroscience@osumc.edu. Applications are due by May 16, 2019 PERSONAL INFORMATION Name: Street Address: City: State: Zip: Home phone: Cell phone: Email address: Gender: Female Male Birth date: Race/ethnicity: African-American Asian Caucasian Hispanic/Latin American Native American Other Where did you hear about the program? PARENT/GUARDIAN INFORMATION Parent/guardian s name: Parent/guardian s occupation: Parent/guardian s cell phone: Parent/guardian s email address:
SCHOOL INFORMATION Current school: Current grade: 11 12 GPA: on a scale of th th What high school science courses will you have completed by December 2018? Biology 1 Biology 2 or AP Chemistry 1 Chemistry 2 or AP Other (please indicate): If selected, indicate how you will travel to/from OSU My parent/guardian will drive me I will drive Other (please indicate): Teacher/Counselor Confirmation Students applying to the Explorations in Neuroscience summer camp must be in good standing academically. Please verify that this student is in good standing in your school. Print name: Title: Signature:
To Whom It May Concern: I authorize my minor child,, to be transported via a rental passenger van and the OSU campus bus system during his/her participation in the Explorations in Neuroscience Camp being held June 3-7, 2019. Parents Printed Name Parents Signature Date
To Whom It May Concern: I authorize my minor child,, to observe a live video feed of a patient undergoing Deep Brian Stimulation Electrode placement surgery during his/her participation in the Explorations in Neuroscience Camp being held June 3-7, 2019. Parents Printed Name Parents Signature Date
Camper s Name: Date of Birth: Address: City, State, Zip: Home Phone: Parent/Guardian Daytime Phone(s): Medical Insurance Company: ID # EXPLORATIONS IN NEUROSCIENCE CAMP Medical Authorization Form Medical Information: Please indicate any of the following that apply to your child: Allergy to a medicine, food, animal or insect toxin Any condition that may require special care, medication or diet ADHD (Attention Deficit Hyperactive Disorder Asthma Seizures Other Heart Trouble Contact Lenses Diabetes Fainting Spells Bleeding Disorders Dentures Please explain all of the items checked above: List any medications your child is currently taking, including over-the-counter. Specify if your child will need to take medication during the program day: Do you know of any health factors that make it advisable for your child to follow a limited program of physical activity or to refrain from participating in any of the program activities? If yes, explain. Mention any recent surgery, illness, broken bones, injuries, allergies, or other physical conditions. Do you have any suggestions on behavior management or special needs for your child? In case of any emergency or illness, every effort will be made to contact the parents or guardians. In the event that contact cannot be made, I hereby grant permission for physicians, dentists, or other licensed health care providers and their designees employees by The Ohio State University to administer outpatient medical, surgical, or dental services as appropriate, or necessary antigens or other injections, to perform emergency procedures as necessary, or to refer to duly licensed medical personal when indicated. Parent/Guardian Name: Date: Parent/Guardian Signature:
CONSENT FOR USE OF INFORMATION AND PERSONA OF A MINOR I hereby grant to The Ohio State University the right to publish, broadcast, webcast, or disseminate in any other form or medium any or all of the following: Stories and/or information about minor for use in news stories, publications, promotional materials, web features and/or any other university purposes. Photographs, video, audio, and other images or likenesses of minor for use in news stories, publications, promotional materials, web features and/or any other university purposes.